A nurse is using SOAP documentation to write a progress note for a client who has cellulitis of the lower leg.

The nurse needs to select all that apply when writing an assessment entry in SOAP documentation.

Redness, swelling, and warmth of the affected area.

Pain level rated as 8/10 on a numerical scale C.

Wound culture results pending.

Risk for infection related to impaired skin integrity.

Applied moist heat compresses to the wound site.

Answer and Explanation

Correct Answer : A,B

These are the only options that describe the subjective and objective data of the patient, which are part of the SOAP documentation method. SOAP stands for Subjective, Objective, Assessment, and Plan, and it is a way of recording patient data in a clear and consistent manner.

Choice C is wrong because wound culture results are not part of the assessment entry in SOAP documentation. They are part of the investigation results, which are usually documented in the objective section.

Choice D is wrong because risk for infection related to impaired skin integrity is a nursing diagnosis, not an assessment. Nursing diagnoses are usually documented in the plan section of SOAP documentation.

Choice E is wrong because applied moist heat compresses to the wound site is an intervention, not an assessment. Interventions are also documented in the plan section of SOAP documentation.

Normal ranges for vital signs are as follows:.

• Blood pressure: 90/60 mmHg to 120/80 mmHg.

• Pulse rate: 60 to 100 beats per minute.

• Respiratory rate: 12 to 20 breaths per minute.

• SpO2: 95% to 100%.

• Temperature: 36.5°C to 37.5°C.

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Correct Answer is B

Explanation

A critical pathway provides guidelines for managing clients with similar health problems.According to the definition from Wikipedia, a critical pathway is one of the main tools used to manage the quality in healthcare concerning the standardisation of care processes.It has been shown that their implementation reduces the variability in clinical practice and improves outcomes.

Choice A is wrong because a critical pathway does not specify the plan of care for clients with different diagnoses, but rather for a specific group of patients with a predictable clinical course.Choice C is wrong because a critical pathway does not describe the roles and responsibilities of each member of the health care team, but rather defines, optimizes and sequences the different tasks (interventions) by the professionals involved in the patient care.Choice D is wrong because a critical pathway does not evaluate the quality and cost-effectiveness of care delivered to clients, but rather aims to promote organised and efficient patient care based on evidence-based medicine.

Normal ranges for COPD are: FEV1/FVC ratio < 0.7; FEV1 < 80% predicted; FVC normal or reduced; TLC > 80% predicted; RV > 120% predicted; DLCO < 80% predicted.

A. Include factual information about what happened. B. State opinions about who was responsible for the error. C. File the report in the client’s medical record. D. Notify the risk management department. E. Discuss possible solutions to prevent future errors.

Correct Answer is ["A","D"]

Explanation

The nurse should include factual information about what happened and notify the risk management department.These actions are part of the steps of reporting medication errorsand the good practice guide on recording, coding, reporting and assessment of medication errors.

Choice B is wrong because the nurse should not state opinions about who was responsible for the error.

This could be seen as biased, unprofessional or accusatory.

The nurse should focus on the facts and the causes of the error, not on blaming individuals.

Choice C is wrong because the nurse should not file the report in the client’s medical record.

This could violate the client’s privacy and confidentiality.

The report should be filed in a separate system that is accessible only to authorized personnel.

Choice E is wrong because the nurse should not discuss possible solutions to prevent future errors.

This could be premature, unrealistic or inappropriate.

The nurse should leave this task to the investigation team or the risk management department, who will analyse the incident and make recommendations based on evidence and best practice.

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A nurse is using SOAP documentation to write a progress note for a client who has cellulitis of the lower leg. The nurse needs to select all that apply when writing an assessment entry in SOAP documentation.

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Naxlex Comprehensive Predictor Exams

A nurse is reviewing a critical pathway for a client who has chronic obstructive pulmonary disease (COPD). The nurse should understand that a critical pathway:.

Correct Answer is B

Explanation

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Correct Answer is ["A","D"]

Explanation

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A nurse is teaching a newly hired nurse about the legal aspects of documentation. Which of the following statements by the newly hired nurse indicates an understanding of the teaching?

A nurse is using SOAP documentation to write a progress note for a client who has cellulitis of the lower leg. The nurse needs to select all that apply when writing an assessment entry in SOAP documentation.

A nurse is using SOAP documentation to write a progress note for a client who has cellulitis of the lower leg.

The nurse needs to select all that apply when writing an assessment entry in SOAP documentation.